suy tim mat bu cap

IEU TR SUY TIM MAT BU CAP
(Management of acute decompensated heart failure)

PGS.TS Pham Nguyen Vinh

Vien Tim TP Ho Ch Minh

BV Tim Tam c

Tam quan trong cua suy tim mat bu cap
Suy tim co trieu chng c nang: My 2% dan so; 6 10%/ ngi tren 65 tuoi; > 10% dan so > 80 tuoiSuy tim mat bu cap (STMBC): nguyen nhan nhap vien cao nhat > 65 tuoi (80%)Nghien cu Acute Decompensated Heart Failure Registry (ADHERE): tuoi trung bnh 27 000 b/n nhap vien la 75
TL: Dec G.W. Management of Acute Decompensated Heart Failure. Curr Probl Cardiol 2007; 32: 319 - 366


T vong do suy tim ngay cang tang (thong ke My)

TL: Adams KF. Am J Med 2001; 110 (suppl 7A): 6S 13S


CHF : Suy tim

CHD : Benh MV

Suy tim ngi cao tuoi (> 65)
T vong trong BV cao nhat, tng ng NMCT capac iem:
* Phan ln do THA, tai cau truc that trai sau NMCT, giam te bao c tim theo tuoi (5%/nam/ > 65)

* 40 50%: suy tim tam trng

* suy tim tam thu hoac tam trng: nguy c tng ng

TL:- Fonarow GC/ the ADHERE committee. Rev Cardiovasc Med 2003; 4 (suppl 7): S21 30

- Smith GL et al. J Am Coll Cardiol 2003; 41: 1510 - 1518


Yeu to benh sinh STMBC
Hau het (> 70%) nhap vien do suy tim man nang hn.> 60% b/n nhap vien v STMBC co benh s:
* BMV (53 70%)

* THA (> 30%)

* rung nh man hay rung nh cn (> 45%)

* T (> 20%)

* roi loan chc nang than (> 20%)
Uong ru nhieu, cocaine, amphetamineCng giap, suy giapThieu mau cap hoac manThuoc: c che calci the he 1, chen beta, chong loan nhp, khang viem khong steroid

Cac nguyen nhan ieu tr c cua STMBC



Sinh ly benh STMBC
Nhieu yeu toSung huyet phoi va/hoac sung huyet tnh mach (qua tai the tch)
* khong kieng c

* khong dung thuoc

* that trai roi loan hn

* roi loan chc nang than

* HA kiem soat kem; rung nh mi xuat vien; TMCB c tim
Hoi chng tim than:
* AGII -> endothelin -1, vasopressin -> nc va muoi, sc cang thanh tim, giam ti mau than

* Giam ti mau than -> AG II


Sinh benh hoc ve ton thng c tim trong ky STMBC

Ton thng c tim: yeu to quan

trong trong STMBC


TL: Maylin M et al. Am J Cardiol 2005; 96 (suppl): 29G

Bieu hien lam sang
Trieu chng c nang: nhay nhat trong chan oan STMBCKho th phai ngoi, cn kho th kch phat ve em: ac hieu nhat (o nhay 23 66%; o ac hieu 52 81%)Ran phoi:- khong gap 80% suy tim man (do gia tang lu thong bach huyet phoi)
- thng xuat hien khi STMBC
Phu ngoai vi: 25% < 70t suy tim man; xuat hien khi STMBCPhan hoi gan TM co: hien ro khi STMBC (do ap lc o ay)Phan biet STTThu vi STTTr: sieu am timBNP, NT pro BNP: giup chan oan va lng nh tien lng


Hai chat ch iem (biomarkers) giup chan oan va lng nh tien lng
BNP hoac NT pro BNPTroponin I hoac Troponin T

Ch nh nhap vien trc trieu chng STMBC


Chng c suy tim mat bu nang :
* Ha HA

* Chc nang than

* Tri giac
Kho th khi ngh
* Th nhanh/ngh

* SatO2 < 90%
Loan nhp lam roi loan huyet ong Thieu mau cuc bo c tim cap

Yeu to tien lng/ suy tim man
Nong o nor epinephrine huyet tngBNPPXTMnh cao thu nhan oxy/ TNGSTuoi caoBenh s loan nhp co trieu chng c nang hoac ot t
TL: Eichhorn EJ. Am J Med 2001; 110 (7A): 14S 35S


Yeu to tien lng/ STMBC



Tan suat t vong hoac tai nhap vien/ nong o BNP luc xuat vien


TL: Logeart D et al. J Am Coll Cardiol 2004; 43: 635 - 641

BNP va Troponins: biomarkers cua tien lng
30 70% b/n STMBC: Troponin I hoac Troponin T* BNP kem Troponin: 12 lan nguy c t vong/ STMBC**
TL:* Gheorghiade M et al. Circulation 2005; 112: 3958 3968

** Horwich TB et al. Circulation 2003; 108: 833 - 838


Roi loan chc nang than: yeu to tien lng quan trong/ STMBC
25% b/n nhap vien/ suy tim: giam chc nang than du ieu tr noi ung 0.1 0.5mg/dL creatinine mau: t vong, thi gian nam vien 0.5mg/dL creatinine mau/ lieu cao li tieu: tang t vong va nam vien


Ba yeu to tien lng xau theo nghien cu ADHERE Registry
BUN > 43 mg/dLCreatinine > 2.75 mg/dLHuyet ap tam thu < 115 mmHg
TL: Fonarow GC et al. JAMA 2005; 293: 572 - 580


Muc tieu ieu tr
Suy tim man:* giam trieu chng, giam nhap vien
* gia tang song con
STMBC:* tng t suy tim man
* tuy nhien, can nhat: giam nhanh trieu chng c nang
Mills R & Narula J: giam nhanh trieu chng va cai thien huyet ong nhng khong lam nang roi loan than kinh the dch (RAAS)


Khao sat va theo doi huyet ong: s o 2x2 cua Nohria

Warm & Wet : phu phoi, huyet ap con tot

Cold & Wet : phu phoi, HA tut

Cold & dry : HA tut


TL: Nohria A et al. JAMA 2002; 287: 628 - 640

Nguyen nhan va x tr/ huyet ong
Warm and dry (am va kho): lam nang suy tim (kho th, met) do thuyen tac phoi, benh phoi tac nghen, nhiem trungWarm and wet (am va t): 50 60% STMBC. Tang tai the tch. ieu tr: giam trieu chng sung huyet ( li tieu, duy tr UCMC)Cold and dry (lanh va kho): < 5%. Giam cung lng tim nhng khong tang c tien tai. ieu tr: truyen dch, tang co c tim khi a u dch (dobutamine)Cold and wet (lanh va t): 20%, e doa soc tim. Nguyen do: mi b NMCT, roi loan nhp, benh van nang hn, khong tuan thu ieu tr


Co can at catheter MP e hng dan ieu tr?
Nghien cu ESCAPE: 433 b/n / 26 c s
- nhom ieu tr noi khoa quy c: da vao trieu chng c nang va thc the

- nhom co at catheter MP
Ket qua ESCAPE:
- tieu ch chnh (t vong, thi gian nam vien): tng ng/ 6 thang

- bien co trong benh vien, thng gap nhom catheter MP (p = 0.04)

TL: ESCAPE Investigators. JAMA 2005; 294: 1625 - 1633


Quy trnh ieu tr phu phoi cap, ha HA va soc

TL : Colucci WS. Treatment of acute decompensated heart failure (Cardiogenic pulmonary edema). 2007 Up to Date. www.uptodate.com


Vai ieu can chu y khi ieu tr STMBC
Ngng dan mach uong va chen beta khi dung thuoc van machTranh dung thuoc tang co c tim e gia tang nc tieu/ suy tim nang vaDuy tr tang co c tim/ b/n l , vo nieu, ha huyet ap keo dai hoac lactic acidosisieu tr tang co c tim ngan han: co the hu ch b/n co hoi chng than tim (cardiorenal syndrome)B/n warm and wet: co the can tang co c tim neu huyet ong suy sup nang hn*
TL: * Dec GW. J Am Coll Cardiol 2005; 46: 65 - 67


Thuoc ieu tr STMBC: li tieu
Li tieu quai (furosemide, torsemide, bumetanide): vai tro chnh trong STMBCLi tieu quai + thiazide: tac dung cong hngFurosemide TTM 1 10mg/ gi: hieu qua hn TMLieu li tieu TM: toi thieu bang lieu ang uong

Li tieu lieu thap hay lieu cao?
Li tieu ngan han: tang hoat than kinh the dch (RAAS, endothelin, BNP)Li tieu lieu cao: tang nhay cam vi UCMC va chen betaNghien cu ADHERE*: b/n co s dung li tieu TM co t vong trong b/n cao hn va nam vien lau hn nhom khong LTTot nhat: li tieu lieu thap nhat co hieu quaNa+ < 130mEq/L: dch < 2L/ngayNa+ < 120 mEq/L: han che dch nhieu hn
TL: * Abraham WT et al. J Am Coll Cardiol 2005; 46: 57 - 64


Thuoc oi khang aldosterone
Khong s dung spironolactone hoac eplerenone/ STMBCLieu spironolactone 25mg/ngay: khi ra vienB/n ang dung spironolactone b STMBC:
* tiep tuc s dung

* ngng spironolactone neu huyet ong khong on, roi loan ien giai hoac chc nang than xau hn.


Digoxin
Cha ro hieu qua tren STMBCNong o digoxin mau > 1ng/dL: tang t vong / moi nguyen nhanChu y: verapamil, flecainide, spironolactone va amiodarone gia tang nong o digoxin mau.

B/n STMBC ang s dung chen beta
Trieu chng c nang nhe, ap ng ngay vi li tieu: khong can ngng chen betaGiam 50% lieu chen beta/ b/n nhap vien ban au v STMBCNgng chen beta khi STMBC dang lanh va t (cold and wet)Nen khi au chen beta lai trc xuat vien

Nghien cu IMPACT HF
(The Initiation Management Pre-Discharge: Process for Assessment of Carvedilol Therapy for Heart Failure)
a trung tam, m, 363 b/n PXTM < 40% nhap vien v STMBC2 nhom:
* nhom khi au carvedilol trc xuat vien (1)

* nhom carvedilol 2 4 tuan sau xuat vien (2)
Sau 6 ngay:
* 91% nhom 1 con s dung chen beta so vi 73% nhom 2 (p< 0.001)

* at lieu muc tieu: 36%/ nhom 1; 28% nhom 2

TL: Gattis W et al. J Am Coll Cardiol 2003; 43: 1534 - 1541


Thuoc dan mach uong
BN ang s dung UCMC hoac chen thu the AGII (uong) :Tiep tuc, can thanNgng, neu : Ha HASuy than cap Kali mauKhong khi au UCMC hoac chen thu the AGII/benh nhan mi STMBC


Thuoc dan mach TTM: vai tro chnh trong STMBC


Cac dan mach trong STMBC
Nitroglycerine: Nitroprusside; Nesiritide (BNP)Chau Au: 32% b/n STMBC s dung nitroglycerineElkayem va c/c (AJC 2004; 93: 237 240): Nitroglycerine du lieu cao (160m/ml) sau 4 6 gi ieu tr van tang ap lc bt mao mach phoi (PCWP)Nitroprusside: hieu qua, nhng can theo doi huyet ong xam nhapNghien cu VMAC*: nesiritide co hieu qua tng ng nitroglycerine
* VMAC Publications Commettee. JAMA 2002 ; 287 ; 1531-1540


Hieu qua sinh ly benh cua dan mach/ suy tim
Dan tnh mach (td: nitrates)
* ap lc o ay

* cai thien sung huyet phoi
Dan ong mach:
* sc can mach ngoai vi

* cung lng tim
STMBC: giam hoac ngng dan mach neu
* roi loan nang chc nang c quan muc tieu (td: than)

* ha huyet ap keo dai (td: HA tth < 85mmHg)

* huyet ong khong on


Hieu qua dan mach so vi tang co c tim/ STMBC
Nghien cu ADHERE registry: ieu tr bang dan mach TM giam t vong trong benh vien cao hn thuoc tang co c tim
TL: * Abraham WT et al. J Am Coll Cardiol 2005; 46: 57 - 64


Thuoc tang co c tim/ STMBC: tang t vong


Thuoc tang co c tim/ STMBC
Dobutamine; milrinoneNghien cu cua Liang va c/s:
* dobutamine TTM 72 gi/ 15 b/n suy tim NYHA III, IV

* theo doi 4 tuan:

- khong t vong

- PXTM / nhom dobutamine
Nghien cu OPTIME CHF: milrinone tang t vong va tai nhap vien/ 60 ngay/ benh tim TMCBPoole Wilson (JAMA 2002: 287:1587 1580): tat ca thuoc tang AMP vong/ te bao c tim -> t vong STMBC

Ch nh thuoc tang co c tim/ khuyen cao
Khuyen cao cua ACC/AHA*: thuoc tang co c tim s dung trong G D cua suy tim (class IIB) giup giam trieu chng hoac ch ghep tim.Khuyen cao ESC**: tang co c tim s dung khi giam ti mau kem hay khong sung huyet, khang vi li tieu va dan mach (class IIA)
TL:* Hunt SA et al. J Am Coll Cardiol 2005; 46: 1116 1143

** Nieminen MS et al. Eur Heart J 2005; 26: 384 - 416


ieu tr loan nhp/ STMBC
Rung nh:
* Digoxin + chen beta ; kiem soat tan so tim

* Amiodarone: lieu nap < 1000 mg/ngay neu suy tim mat bu nang

* chuyen nhp/ soc ien: au that ngc hoac huyet ong khong on/ rung nh (Heparin khong phan oan neu RN > 48 gi)
NTT that hoac nhanh that khong keo dai:
* khong x tr neu khong trieu chng

* can tm nguyen nhan: K+, Mg++, hoat giao cam

* Amiodarone (0.5 1mg/ ph TTM) hoac Lidocaine 0,5 mg 2mg/ph TTM

* ieu tr duy tr: chen beta, sotalol, amiodarone


Cac thuoc ieu tr STMBC con ang nghien cu
oi khang endothelin 1: Tezosentan, bosentanChat nhay cam calci: Levosimendanoi khang vasopressin: Conivaptan, lixivaptan, tolvaptanKhong thuoc nao c chng minh giam t vong

ieu tr bang dung cu
(Tr giup tim bang c hoc)
Ch nh : ch so tim < 2L/ph/m2, HA tthu 18mmHg (mac du u thuoc)Bong doi ngc noi MCDung cu tr that trai (LVAD left ventricular assist device)CAFA : continuous aortic flow augmentationSieu loc (ultrafiltration) : thai dch khong anh hng en chat ien giai, hormonesSystem 100 from CHF Solutions Inc : dung cu sieu loc t xam nhap.


Tom tat ieu tr / Ket luan
Th oxy : mask, thong kh tr giupLi tieu quai TM hoac TTMMorphin sulfate 2-4mg TMDan mach TTM (Nitroglycerine, Nesiritide)Tang co c tim TTMTr giup tim bang c hocSieu loc

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